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December 29, 2010

Q: Anemia and Running.

A:

In anticipation of heading up to altitude for 4-5 weeks starting Jan 10th, I got some blood work done to check my iron stores and the health of my red blood cells. It had been 3 months since I last checked, and my ferritin (the savings account of long-term iron stores) had dropped from a healthy 88 to an alarming 30 something. That’s still not anemic, but in my experience, once I’m in the 20’s I start feeling like doo doo. And I have been feeling a bit like doo doo lately, so the significant drop should not have come as a surprise.

The thing is, I’ve gotta bring my numbers up pronto because altitude is the bomb. Short bursts of altitude training have historically had a great effect on my training and racing. Oxygen is in shorter supply up there, making aerobic exercise extra challenging. My body attempts to make more red blood cells so there are more vehicles to carry oxygen through my body tissues. And what material does the body require to make hemoglobin-containing red blood cells? Iron. When the demands for iron are larger than what you are getting in your diet, then your body goes to the savings account: ferritin.

The long and short of it is, its hard enough to keep from becoming anemic at altitude when you start with a high ferretin level. I’ve spent the past 10 days trying to boost mine back up, and will continue to do so until Jan 10th. If my blood test doesn’t look much improved by the 9th, I won’t be going to Albuquerque. There would be no point; there’s a good chance I’d be unable to recover properly from my training sessions, and I’d probably end up run down and anemic. There’s a small chance I’d be just fine, but with 2011 being “the year of consistency at all costs,” I won’t take a big risk like that.

I’m very confident that I can get my numbers up. I NEED to. I want to get that training block in so badly! I love Albuquerque and there is so much to be gained! Luckily, iron supplements are perfectly legal, cheap, and readily available. My approach to the mega boost is three-fold:

2. Take an elemental iron supplement twice a day with O.J. on an empty stomach, 15 minutes before a meal.

3. Avoid iron inhibiting foods (there are many sources for this, but this is a basic one) and beverages with my iron rich foods or supplements. Pair my steak and supplements with foods that encourage iron absorption.

One thing I haven’t done well in the first 10 days is avoid processed wheat. With the holidays, there are way too many good cookies and pastries around, and my discipline has left something to be desired. Had I been flat-out anemic, I would have sacrificed all that crap. Hopefully the last 10 days of all-star eating will boost me up where I need to be.

Just to let you know Meggie,
Drinking coffee at the same time that you take iron or eat iron-rich foods interferes with absorption. If you drink coffee and are worried about iron levels, I would make sure that you space the iron supplements at least two hours from your last drink of coffee.
-Laura

Very informative post. I think this is an important topic since training and balanced food/nutrition intake need to go hand-in-hand. Point #3 about iron inhibitors is key, and I am guilty of overlooking that one (can’t resist the coffee). Thanks, Lauren!

I don’t think you have to give up coffee (I am an addict as well). I think you just want to make sure you have it at a time when you aren’t trying to boost your iron. The easiest times to boost your iron are first thing in the morning and at dinner. During the middle of the day, you can focus on calcium and other things so you don’t neglect your overall health in an attempt to boost your iron.

I’ve switched my morning routine as follows:
Wake up to orange juice and iron supplement right away on an empty stomach.
Wait 15 minutes to eat breakfast or after my morning run, (avoiding iron inhibiting foods).
Have coffee 2 hours after the iron supplement, around 10am.

Great post! I think this is an incredibly important topic for runners, especially female ones! I, too, struggle with anemia every marathon training cycle and constantly feel like doo doo so I feel your pain!!! I think your 2011 goal is great – consistency! I can’t wait to read about how this, and your all star eating, plays out in your success.

I have found that eating foods high in Vitamin C really have a huge affect on how quickly and efficiently I am able to absorb iron. My fave all star vit- c and iron combo meal is : a big juicy steak, overloaded with red bell peppers, tomatoes, spinach and broccoli, along with some quinoa on the side.

I also eat quinoa flakes for breakfast. You can find them at any natural grocery store and they are already cooked, like oatmeal. All you need to do is add water and micorwave for 2 min and voila- a natural, protein rich breakfast! Not everyone is a fan of the taste ( it’s a little drier/ chalkier than oatmeal) so instead of microwaving it in water, i soak it in 100% apple juice and microwave for 3 min. Much tastier! Just add fruit and it’s a perfect breakfast meal, and the vit c and iron combo again do wonders. Just an idea- these are my day to day go tos.

I start to suspect anemia when my tiredness feels more like weakness and melancholy. I also look a bit pale.
I had a team mate once who could rub the band of her gold ring across her forehead/cheek and tell if she was anemic or not. If it left a black line, she was anemic!

Lauren,
I too struggle with anemia and I am 53. I have read there is an anemia called “foot strike anemia”……if you can believe it.

My doc says to score the iron tablets, as they will not be absorbed well unless they are. Just use a sharp knife to mark a few lines in the green shell. And, my understanding is you need more than a glass of orange juice.

As someone who struggles with iron deficiency (and I’m a vegetarian) how does processed wheat interfere with the absorption process? Just curious because I’m a high mileage runner who lives at altitude and iron levels are obviously a big concern!

The main problems with wheat are two-fold (three-fold if you are gluten intolerant, but we will ignore that one for now.)

1. Wheat fiber: http://www.ncbi.nlm.nih.gov/pubmed/2820048 Basically, bran has phytates which interfere with iron absorption. Processed wheat in cereals and baked goods usually strip the bran off the wheat and then add it in later so they can say it has fiber in it. Its easier to make wheat products with stripped down soft flour than using sprouted whole grains in their original form from the beginning. Look at the ingredients list for things containing wheat…if wheat bran is listed as separate from wheat flour, in my book its bad news.
2. Quick breads, scones, cookies, baked goods, etc use a good amount of baking powder and self-raising flour, which is high in phosphates, and bad for iron absorption. Runners are prone to order the “healthy” muffins and scones from coffee shops, but oftentimes these are even worse for iron absorption because they use processed flour and then add in bran and fibrous stuff after the fact so it looks all grainy.

So its not wheat itself, but what we do to it that messes our body up. When you are trying to boost your iron, I recommend sprouted grain breads for your sandwiches, plain white flour tortillas rather than bran-added ones, and laying off all baked goods for a while. Sucks but its worth it.

Does anyone else get terrible stomach aches from iron supplements? I tried your suggestions of the tablet and OJ on an empty stomach, and almost immediately was hit with dizziness/nausea… any thoughts?

Hi Louise, Yeah that has happened to me before too. Now I take an iron supplement called INNATE hematic response. Its 100% whole food sources and I get it at Bioletics.com I have had no stomach problems with it at all.

Thanks for this post; very helpful!
As a highschool runner who just started taking iron supplements (twice a day) a few days ago for very low ferretin levels, about how long does it take for it to start kicking in and feeling good again in workouts/races? Thanks!

I came across this post again and wanted to know if over the last several years since this was written if you’ve continued to struggle with your ferritin since then? As an athlete I’ve struggled to manage my ferritin and it has begun to get frustrating. There was a while I was getting a blood panel done at least every 6months, mostly to track our athlete specific trends for our team physiologist. Two years ago now my ferritin took a nose dive from 72 down to 30 and has since then continued to slowly dwindle. Currently at a pale 19. The first dive happened after I moved away from home (where I ate game meat regularly) to living in the Olympic training center, so I could see the dietary link to the decline. However since then I have been living outside a cafeteria setting, taking periodized iron supplements ( recently trying the liquid kind) but my stores just keep sliding. I’m wondering if you have found any strong link with gluten? My diet is primarily based on vegetables (leafy greens, etc), hearty grains, and lean red meat. With a bunch of endurance athletes in the house we eat pretty well but we do eat a bit of (very gluten-y) bread…. I guess I’m grasping for straws… help?

Corrine,
There are links between wheat and iron for some people, but from what I’ve read it’s only an issue when pairing the iron with wheat at a given meal. If you have a turkey sandwich for lunch and then a steak and potatoes for dinner, that shouldn’t matter.
If you have celiac disease, then gluten could definitely be the cause of your declining iron, but it should also be causing a decline in lots of other vitamin and mineral stores as well. I’d get a blood test for celiac or gluten intolerance before sacrificing your diet unnecessarily. Bread is just too damn good. But yeah, don’t eat it with your iron if you’re having trouble keeping the iron up.
Too much fiber can interfere with iron absorption too. This is the secret culprit for most athletes who are eating iron but still experiencing low blood levels. A lot of athletes inadvertently make it harder and harder to absorb iron because they are trying so hard to get raw veggies and whole grains in, but fiber gets things moving quickly through the system, and you can have too much of a good thing. Less time in the intestines means less time for vitamins and minerals to absorb. If you have frequent loose stools, this probably applies to you.
The daily recommendation for fiber is 25-35 g per day. Athletes trying to be really healthy often eat double that, especially if they have high fiber cereals or products that fiber is added to to lower the overall “net effective carbs” or things of that nature (low carb tortillas for example). Count up what you are getting per day for a couple days and then make adjustments. You can always cook your veggies a little more to break down the fiber, or eat lower fiber fruits, or a simpler bread.
Worst case scenario, if your iron stays low like that and you can’t bring it up with diet and supplements, you should talk to a doctor. Anemic women are prescribed an iron infusion in situations like these, whether they are athletes or not. Anemia plagues women all the time due to periods and god knows what else. When people have distressed guts that won’t absorb the iron, the only way to get your levels up is to bypass the gut and get the iron into the bloodstream through an IV. But all infusions of any kind are considered a prohibited “method” against WADA/USADA rules unless a doctor feels it is medically necessary and the appropriate TUE documents are filed.

For the person experiencing anemia that does not respond to iron supplements, you might want to look into checking for h pylori and treating that if positive and that may help your condition. This digestive bacteria can cause reduced acidity in the stomach and also uses up iron in its own metabolism.

I was recently diagnosed with anemia, my ferritin was 5! A doc last year simply didn’t catch my anemia, my CBC was on the border of normal and she did not check my Iron binding capacity, iron or ferritin at all. I’m slightly angry about this exhausting year of my life, but glad my new doc is sharp. I’m using FeoSol Bifera which contains proferrin, also trying Floradix liquid iron. Ferrous sulfate felt like a mule had kicked me in the gut hard! Considering a pregnancy again and I know I was anemic last time due to pica, I think I’ve been anemic for 5 years or more. Sad. But I’m living in the moment and moving forward thankfully. Thanks for this post and this topic, as someone with a science background I find it fascinating.

Our daughter has been struggling with her HS XC training and races for 2 years. We just learned about testing for Ferritin levels and took her in to have hers done. We just got her results back–it was a 5!!

Now at least we know what the issue is with her lack of energy, lack of improvement, constant viruses and injuries, etc.

I’m a bit nervous that it was SO low. Any insight on that?

Also, my research has lead me to this one. An iron supplement that is from the same source as red meat. Have you heard of it?

Hi Charlie,
Sorry for the late reply. I just saw this comment. I’m sure you have it all resolved by now but I’ve heard of several people getting into the single digits on their ferretin tests. Not a great situation! But yes, improvable. When the iron rebounds, you feel like a completely different person. If her iron drop was accompanied by weight loss, you should have your red flag up, but if she seems to be eating normally, maintaining her weight, etc, the issue is probably not as complex. Many high school and college runners start getting overly picky with their diet and obsessing over body image to the point where they deplete their bodies of vital nutrients. Their behavior can be overlooked by adults because the athlete portrays that they are simply doing what serious athletes do, and unknowing parents believe them. Anyway, I hope the iron issue has resolved and that everything is groovy.
L

Running long distances used to be so easy for me but recently even completing a 2 mile run it hard. Also 8 min pace used to feel comfortable but now I can barely run a 10 min pace… My legs are always fatigued and my breathing is out of control. I’m going to be seeing my doctor in a few weeks to talk to her about it but do you think that this could be an iron deficiency?

@Elizabeth: the same scenario for me. I have been taking an iron supplement for about two months now, but to no avail and I have a ferritin of 10.
I will let you know what the solution is if I ever start feeling better! I wish the best of health and speediness to all!

@Libby I went to the doctor over a month ago and found out that I am severely anemic…. I was at a 3 and to run i should have been at a 30 on the hemoglobin scale and for iron it was a 6 when i needed to be at a 12. I have been taking 3 iron pills a day (over 1000mg of iron) and i feel amazing and I am running paces that I was able to run before. 8 minute pace is now do-able again. Before I started getting my iron and hemoglobin up I was running 10/11/12 min miles and feeling like I was dying slowly. I no longer have that feeling of being weighed down with heavy legs and heavy labored breathing. I feel like a runner again and it is amazing. I am feeling better and better by the day. I highly recommend seeing a doctor if you think that you are anemic. I feel like my self again, I feel happy 🙂
-Elizabeth

Just read this thread – really helpful. I have never had anaemia before (even when I had a period that lasted 3 months!) but was diagnosed with it 3 weeks ago with a ferritin level of 5. My time for 5k had fallen from under 26 minutes in January to over 32 minutes in July! I thought I had a healthy diet and lifestyle but reflected that I had reduced my meat consumption significantly 12 months ago and also started eating my main meal at lunch time when I would also have a cup of coffee/ green tea or matcha green tea. I had an iron infusion two weeks ago and started to eat kale / liver etc, to not drink any green tea and to only have a cup of coffee at least one hour from a meal, plus I’d add vitamin C to meals. Anyway, I’m feeling about 80% now and am now running 5k at just over 30 minutes – still slow for me but better. I also managed a long run of over 12 miles when I’d struggled with 10 miles the week before the infusion. My legs ache much less than than they have been. However I still get breathless, particularly in the first 5 minutes and when I speed up. I’m due to have an endoscopy and colonoscopy in the next couple of weeks but that is more as a precaution than because the doctor suspects anything.

My questions are – am I expecting too quick a recover and is doing the half-marathon that I’m entered for on 7 September optimistic (I’d entered it as I ran 2:02 in March so wanted to get under the 2 hour mark but realise that I need to save that for the next one and will just be happy to finish).

Hi Lauren! I understand that this is a very old post put it applies well to my situation. I’m a high school runner with low iron. As well, I’ve struggled with amenhorea for 3.5 years. I’m now experiencing pain in my foot that my doctor believes might be a fracture. Of course if it is a fracture, I will not be competing this outdoor season. I’m looking for advice when it comes to competing if my foot is not fractured. Do you think it would be valuable to not run this season to restore my cycle and iron? I will be running next year at a large, competitive university. Any advice you have would be so greatly appreciated. By the way, loving the ROO podcasts!!

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